First Name *

Last Name *

Address *

City *

State *

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY PR VI Other

Zip *

Email *

Cell Phone Number *

Prince of Peace is supportive of MomCo members. One way to live this out is by getting to know your whole family. Please provide information for all children even if they will not participate in MomCo Kids/Childcare.

MomCo Kids/Childcare has a fee included with this registration that will apply to any child (infant to Grade 5) who may need care regularly or at some point during the year such as MEA or Spring Break.

If you do not request MomCo Kids/Childcare at this time but find that you need it at a later date, there is a $5.00 fee per visit. This is payable (cash or check) when you bring your child(ren) to MomCo Kids/Childcare.

Please contact Jeanne Kalsow jkalsow@popmn.org in advance so the staff knows to expect your child(ren) if you need care and they are not included in this registration.

If you are enrolling your child(ren) in MomCo Kids/Childcare, you may be expected to volunteer up to three times during the year.

For this reason Prince of Peace requires background checks. This is done online by a third party and you will receive an email with instructions.

After completing the form, another page will come up regarding payment for MomCo/Childcare and the opportunity to donate toward scholarships for moms in need or other fees.

CHILDREN'S INFORMATION - please begin with the youngest

First Name (1) *

Last Name (1) *

Birthdate (1) xx-xx-xxxx *

Please describe any food allergies, dietary or other special concerns (developmental, social, etc.). List NA if none. (1) *

Are immunizations up to date? (1) *

Yes

No

If immunizations are not current, please explain. (1)

Enroll in MomCo Kids/Childcare? (1)

Yes-regularly

Yes-occasionally

No childcare is needed

First Name (2)

Last Name (2)

Birthdate (2) xx-xx-xxxx

Please describe any food allergies, dietary or other special concerns (developmental, social, etc.). List NA if none. (2)

Are immunizations up to date? (2)

Yes

No

If immunizations are not current, please explain. (2)

Enroll in MomCo Kids/Childcare? (2)

Yes-regularly

Yes-occasionally

No childcare needed

First Name (3)

Last Name (3)

Birthdate (3) xx-xx-xxxx

Please describe any food allergies, dietary or other special concerns (developmental, social, etc.). List NA if none. (3)

Are immunizations up to date? (3)

Yes

No

If immunizations are not current, please explain. (3)

Enroll in MomCo Kids/Childcare? (3)

Yes-regularly

Yes-occasionally

No childcare needed

First Name (4)

Last Name (4)

Birthdate (4) xx-xx-xxxx

Please describe any food allergies, dietary or other special concerns (developmental, social, etc.). List NA if none. (4)

Are immunizations up to date? (4)

Yes

No

If immunizations are not current, please explain. (4)

Enroll in MomCo Kids/Childcare? (4)

Yes-regularly

Yes-occasionally

No childcare needed

Permission to use child(ren)'s photo (no names) in promotional materials, print and social media. *

Yes

No

Please read the childcare fee options carefully and enter "1" for your selection. If you have more than one child needing childcare, you will select "1" for the Two+ Children option.

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